Epinephrine is widely used and recommended by Advanced Cardiovascular Life Support (ACLS) in out-of-hospital cardiac arrest (OHCA), but its effectiveness in neurologic outcomes has never been truly established. To verify effectiveness of epinephrine confounders, such as patients, CPR quality, CPR by bystanders, time from call to arrival at scene or hospital, and much much more, must be controlled for in a trial. This type of study is not easily performed due to ACLS being the current standard of care.

What Studies Have Evaluated the Effectiveness of Epinephrine in Out-Of-Hospital Cardiac Arrest?

Holmberg M et al. Resus 2002(12104107) : Use of epinephrine in OHCA was an independent predictor of increased mortality.

Ong MEH et al. Ann Emerg Med 2007(17509730) : Use of epinephrine in OHCA was not associated with mortality benefit.

Olasveengen TM et al. JAMA 2009(19934423) : Use of epinephrine in OHCA was associated with increased Return of Spontaneous Circulation (ROSC) but was not associated with mortality benefit.

Jacobs IG et al. Resus 2011 (21745533) : Use of epinephrine in OHCA was associated with increased Return of Spontaneous Circulation (ROSC) but was not associated with mortality benefit.

Is There a Larger Study Looking at the Use of Epinephrine in OHCA? (22436956)

What did they do:

Prospective, Non-Randomized, Observational Propensity Analysis

417,188 OHCA Cases in Japan

Outcomes:

ROSC

1 Month Survival

Survival with Good or Moderate Cerebral Performance Category (CPC) 1 or 2

This was an observational study. In other words use of epinephrine was not randomized which can cause a selection bias of what patients got epinephrine and which ones didn’t

Data on in-hospital CPR quality was not included in this study and could be a confounding factor into neurologic outcome and survival not taken into account.

There is no standard regimen for OHCA once the patients made it to the hospital (i.e. Induced therapeutic hypothermia, cardiac catheterization, and/or use of vasopressin)

The number of epinephrine doses received once in the hospital were not recorded

Conclusion of Study: In Japan, the use of epinephrine in OHCA increases the chance of ROSC, but does not increase survival with good neurologic outcomes at one month.

What is considered a “good” Cerebral Performance Category (CPC)?

A “good” outcome would be the ability to perform basic tasks of everyday life, such as eating, bathing, dressing, toileting, and transferring or a CPC score of 2 or less.

Clinical Bottom Line: ACLS is still the standard care in OHCA, which means we still give epinephrine, but the ACLS algorithm should be readdressed and our focus should instead focus on high quality, uninterrupted CPR and early defibrillation.

Hello John,
Yes I have heard of the PARAMEDIC2 Trial and anxiously awaiting the results. The Japanese study above is over 400,000 patients with OHCA and although not a true RCT, its hard to ignore the results. I am interested to see what this new study shows. Appreciate you reading and the link.

[…] without a very lengthy explanation. Epinephrine in cardiac arrest was already covered on REBEL EM (Is It Time to Abandon Epinephrine in Out-Of-Hospital Cardiac Arrest?). I will often hang an epi drip at 0.5 mcg/kg/min instead of having team members distracted by […]